Managing the Mental Health Practice

Over the past decade or so, medical office training has become big business. However, few of those programs distinguish between medical office management and managing a mental health practice. While medical office management focuses a lot of attention on coding and billing procedures and multi-tasking phone lines and 15-minute appointments, managing a mental health practice requires excellent one-on-one people skills and the ability to handle constant upheaval. Due to the endless possibilities for the organization of a medical and mental health practice, the tips in this article focus on the outpatient private therapy practice.

A mental health practice does not require learning long lists of CPT (Current Procedural Terminology) and ICD (International Classification of Diseases)-9 or -10 codes. Unless there is a psychiatrist on staff, billable codes are very few. Although the ICD or DSM-IV (Diagnostic and Statistical Manual) codes may be more lengthy, each mental health practice tends to have certain specialties preferred by the provider. Rather than the memorization skills needed for medical office management, managing a mental health practice calls for adaptability.

Patients seeking treatment at a mental health practice are generally there for three reasons: they have reached the “end of their rope” and are making a desperate cry for help; their children are out of control and causing the entire household to fall apart; they have been ordered to seek treatment by either the courts or an agency trying to help a dysfunctional person or family. All three of these scenarios have one thing in common – desperation. Understanding how emotional turmoil affects a person’s behavior is crucial to gaining and keeping patients in a mental health practice.

Emotional disorganization often causes the sufferer to be irritable and easily annoyed. This trait may become evident at the very first phone call. Keep in mind that this person has probably been suffering for a long time and he or she has finally made the decision to seek professional help. Now, you are telling him the next available appointment is two weeks out. And no, the office is not open nights and weekends, nor can we see you on your lunch hour because we have to eat, too. People have no qualms about taking time off work to go to the doctor for flu symptoms. Taking time off to bring one’s son to the “shrink” is a different matter entirely. The ability to stay calm and polite in the face of unreasonable agitation, and to step in to take the abuse when other employees are ready to run out the door screaming, is a necessity when managing a mental health practice.

Another manifested trait of emotional difficulties is lack of attention, concentration, and short-term memory. Generally, this trait comes into play when scheduling appointments. Since therapy appointments are usually set up for a week or two ahead, or a month during the phase-out period, you have about a 50/50 shot that the patient will remember. People usually will remember appointments for blood work or MRI’s and other medical tests. These tests are not a part of the patient’s normal routine, so the unusual nature helps with committing it to memory. Once patients have had three or four mental health visits, though, it becomes more routine and less memorable. Adeptly managing a mental health practice means being able to organize databases and set specific guidelines and times for reminding patients about the appointment. The manager also needs to have in place a tracking system for missed appointments. Not only do missed appointments mean the mental health practice is losing money, but it also means the patients are not getting better. Depending on at what point the patient is in therapy, it is easy to sink back into old routines, inappropriate behaviors, and mood disturbances. Managing a mental health practice requires following patients closely and providing memory aides to ensure they get the most out of the therapeutic process.

Stress reduction seminars always preach one particular principle – don’t take your work home with you. This adage is vital when working in the mental health practice. For the first two weeks after I started working for a clinical psychologist, I went home every night and had vivid dreams and nightmares. Children being abused, shadows chasing me through dark alleys, my son being alone and in a place I couldn’t reach; all were variations of themes with which I was coming in contact at the office. Managing a mental health practice means you will be exposed to the worst, most bizarre, and predatory extremes of the human psyche and human behavior. In the average general practitioner’s medical office, you can take comfort in the fact if Ms. Jones follows the doctor’s orders and takes the medication, her sinus infection will go away. Baby Jones’ rash will disappear in a few days, and even Mr. Jones’ diabetes is responding well to diet and insulin.

In the mental health practice, when a seven-year-old child has been abused, neglected and abandoned, how do you tell yourself honestly that he will, without a doubt, get better? You don’t know if he will or not. Some of the most extreme behaviors may disappear as the child learns through play therapy how to properly express anger or to deal with separation anxiety. But as that child matures and his emotional capacity matures, he will often re-live the early experiences. Issues that seemed to disappear at age eight may reappear at age fourteen. Girls, and boys, sexually abused may never gain the capacity to have a normal relationship. The paranoid schizophrenics may improve with the new medication, but will the voices ever really go away? You can’t know. Patients build up tolerance to medications so that previous doses are no longer effective. Acute stress, which we all experience from time to time, may be enough to send the person spiraling back to pre-therapy psychoses. Bipolars will stop coming to therapy when they enter a manic phase because they are now on top of the world and life has never been grander. But when they plummet back to the depressive phase, can you convince them to come back to treatment before they take their own lives?

The human brain is a miraculous creation that depends upon finely-tuned processes to function properly. The effects of that creation malfunctioning, whether from internal or external influences, results in behaviors ranging from violent outbursts to near catatonia. Managing a mental health practice brings you into uncomfortable closeness with the sometimes frightening and always awe-inspiring results of a brain gone wrong. Take that intimacy home with you, and it will permeate every aspect of your life.

Both medical office management and managing a mental health practice require the inescapable skill of insurance knowledge. Frustrating as it can be, all insurances are not created equal. Coverage for mental health services is not the same as coverage for medical services. Some insurance plans may cover only 50 % of mental health services. Most require payment of larger deductibles than that for medical treatment. Insurance plans within the same company don’t necessarily provide the same coverage, either. For example, Blue Cross & Blue Shield, one of the nation’s largest insurance providers, has a multitude of different plans within the company. For mental health treatment, some of those plans cover 50 %, some cover 80 %, some cover 100% with rigid criteria; some cover sessions with only doctorate level Ph.D.’s and PsyD.’s, while some cover LPN’s and social workers also; some allow only fifteen or twenty visits a year. Most plans will not pay for evaluations that have to do with court proceedings, school placement for learning disorders, or personality testing (required in some states) prior to gastric bypass surgery. Just because an insurance company paid a certain amount for one patient does not mean it will cover the same amount for a different patient.

Some patients have a difficult time understanding that the insurance coverage is different for mental health than for medical. Unfortunately, that difference is often enough that the patient cannot afford to pay the deductibles and co-pays. The laws are slowly changing and requiring insurance companies to provide more coverage for mental health treatment. However, until the “powers that be” realize that mental disorders can be just as debilitating as medical problems, insurance companies will continue to provide sub-par coverage, robbing a certain percentage of the population of necessary treatment. Managing the mental health practice means you have to be familiar with insurance plans, which plans pay for what, and for whom the coverage is provided. This familiarity also means that you have to be prepared to look a person in the eye, knowing this single mother of two children with severe Attention Deficit Hyperactivity Disorder can’t afford it, and tell her that instead of the $20 she is used to paying the medical doctor, she owes the counselor a $500 deductible plus 50 % of each visit.

Managing the mental health practice requires a high level of sensitivity and insight rarely touched on in medical office training. If the patient on the phone says it is an emergency, you don’t know if Junior just set fire to his bed or if the patient is sitting on her bed with a bottle of pills in her hand. You have to know which patients have severe anxiety so you can schedule them at a time when the waiting room has few people in it, or have an empty room available for that patient to wait in. You have to be able to calm other patients down when they hear a child screaming from the play room because the therapist is making him pick up the toys he just knocked off the top shelf. You have to be able to ignore the person carrying on a conversation with Joe, when that person is the only one who can see Joe. So if you thrive in a chaotic, bizarre but never boring environment, then managing a mental health practice is the job for you.

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